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Prior authorization for medical necessity may be required. Must not be used concurrently with inhaled tobramycin or Cayston.

BINOSTO®

01/01/13

The limits are 4 tablets per 28 days.

BIO-T-GEL®

10/01/12

The limits are 2 packets per day.

BIVIGAM™

01/01/15

Prior authorization for medical necessity is required.

BONIVA®

06/01/05

The limits are 1 tablet per 30 days for Boniva 150mg.

BOSULIF®

11/15/12

Prior authorization for medical necessity is required. The limits are 1 tablet per day.

BOTOX®

01/01/15

Prior authorization for medical necessity is required.

BREO ELLIPTA®

01/01/14

The limits are 1 inhaler per month.

BUNAVIL®

01/01/15

Prior authorization for medical necessity is required. The 2.1mg film has a quantity limit of 3 per day. The 4.2mg and 6.3mg film has a limit of 2 per day.

BUPHENYL®

07/01/13

Prior authorization for medical necessity is required.

BUPRENORPHINE

04/01/16

Prior authorization for medical necessity is required. The limits are 5 tablets per 90 days.

BUTALBITAL COMPOUND

04/01/13

The limits are 6 tablets per day.

BUTALBITAL/ACETAMINOPHEN

04/01/13

The limits are 6 tablets per day.

BUTRANS®

04/01/11

The limits are 4 transdermal systems per 30 days.

BYDUREON®

04/01/12

Bydureon may be subject to step therapy requirements. Patients must have trial and failure of one or more of the following antidiabetic agents: metformin, sulfonylurea, combinations of metformin or sulfonylureas, or basal insulin (Lantus or Levemir). The limits are 4 vials or pens per 28 days.